靶向药物不良反应的认识与思考

新的靶向药物出现提高了抗癌疗效,降低了毒性,使转移性恶性肿瘤患者从治疗中获益。靶向药物耐受性好,通常出现轻微或中度的毒副反应。尽管大多数不良反应是可以得到迅速处理的,但是严重的甚至危及生命的不良反应仍能够发生。因此,为更好地指导临床实践工作,该文综述了实体瘤治疗中常用靶向药物的主要不良反应和安全数据,并按照药物的作用靶...     

First‐line therapy for post‐traumatic stress disorder: A systematic review of cognitive behavioural therapy and psychodynamic approaches

Background

Despite evidence supporting cognitive behavioural therapy (CBT)‐based interventions as the most effective approach for treating post‐traumatic stress disorder (PTSD) in randomised control trials, alternative treatment interventions are often used in clinical practice. Psychodynamic (PDT)‐based interventions are one example of such preferred approaches, this is despite comparatively limited available evidence supporting their effectiveness for treating PTSD.

Aims

Existing research exploring effective therapeutic interventions for PTSD includes trauma‐focused CBT involving exposure techniques. The present review sought to establish the treatment efficacy of CBT and PDT approaches and considers the potential impact of selecting PDT‐based techniques over CBT‐based techniques for the treatment of PTSD.

Results

The evidence reviewed provided examples supporting PDT‐based therapy as an effective treatment for PTSD, but confirmed CBT as more effective in the treatment of this particular disorder. Comparable dropout rates were reported for both treatment approaches, suggesting that relative dropout rate should not be a pivotal factor in the selection of a PDT approach over CBT for treatment of PTSD.

Conclusion/Implications

The need to routinely observe evidence‐based recommendations for effective treatment of PTSD is highlighted and factors undermining practitioner engagement with CBT‐based interventions for the treatment of PTSD are identified.     

Attitudes towards psychotherapy manuals among clinicians treating eating disorders

Clinicians have relatively low uptake and implementation of evidence-based psychotherapies for the eating disorders, and this problem appears to be associated with low use of manualized approaches. This study examines clinicians' positive and negative attitudes to manuals, and possible beliefs and emotional factors that might drive those attitudes. The participants were 125 psychological therapists working with eating-disordered patients. Each completed standardised measures of attitudes to manuals and emotional states. A number of beliefs about the content of manuals were associated with both positive attitudes to the outcome of treatment and negative attitudes to their impact on the treatment process. In addition, a more positive mood was associated with more positive attitudes. Suggestions are made regarding how attitudes might be made more positive, in order to facilitate the use of evidence-based therapies for eating disorders.     

Research in person‐centred,experiential and humanistic counselling and psychotherapy: Meeting new challenges

As a result of the programme of research into client‐centred therapy led by Carl Rogers, the humanistic therapies could claim, in the 1950s, to possess a comprehensive evidence base. Over the following decades, however, there was a marked decline in the productivity and influence of research into person‐centred and humanistic therapies. The present paper celebrates the publication of three books that mark a resurgence in research into these approaches, and comments on emerging themes and trends.     

Disordered Attention: Implications for Understanding and Treating Internalizing and Externalizing Disorders in Childhood

In this article, we present evidence that disorders of attention are present in wide range of psychological disorders, and that the appropriate assessment and treatment of these attention difficulties can be an important adjunct to traditional therapeutic approaches. We review approaches to attention training in some detail and discuss how attention-focused treatment might be implemented in clinical practice.     

Defining and Measuring Mechanisms of Change in Psychological Therapies: The Path Not Taken

Metcalf and Dimidjian (this issue) have provided an important review of the current evidence base for mindfulness‐based cognitive therapy (MBCT) and presented a helpful summary of the proposed mechanisms of change. It is necessary to engage in a continuous dialogue regarding the evidence base for change mechanisms, and the article by Metcalf and Dimidjian highlights an important barrier of concern to the field of treatment outcome research. The present commentary aims to expand the discussion regarding the definition, measurement, and evaluation of “mechanisms of change.” Using MBCT as an example, this commentary addresses the ambiguity surrounding the definition and operationalisation of these mechanisms in research on psychological therapies and how the method of measurement may impact the results obtained in clinical trials. It is argued that a potentially fruitful avenue of future research would involve investigation of techniques, important client‐therapeutic processes, and mechanisms in a single study in order to comprehensively evaluate how change occurs.     

Welcome to the ‘Paradigm War’: the case of antidepressant medication

Mindfulness-based therapies are a recent development within the cognitive-behavioural tradition and an important element of the third wave cognitive behavioural therapy models. A number of these therapies could be considered to have mindfulness as a major component of the therapy. There has been a considerable growth of interest in these therapies with an accompanying increase in their evidence base. While a number of reviews have been conducted, these therapies were not comprehensively appraised. The most prominent of these therapies, mindfulness-based cognitive therapy, was developed to reduce relapse in recurrent depression. We conducted a meta-analysis which looked at therapies considered to have mindfulness as a major component. We investigated whether this group of therapies was effective in reducing current depressive symptomatology as measured by the Beck depression inventory (BDI). A total of 11 studies were included in the analysis. We found a significant mean reduction score in current depressive symptomatology, as measured by the BDI, of 8.73 points (95% confidence interval?=?6.61, 10.86). We found evidence for the effectiveness of these major-component therapies in reducing levels of active depression. The robustness of these findings is discussed alongside the implications for research and practice within the context of the current literature.     

Complementary and alternative therapies for cerebral palsy

The optimal practice of medicine includes integrating individual clinical expertise with the best available clinical evidence from systematic research. This article reviews nine treatment modalities used for children who have cerebral palsy (CP), including hyperbaric oxygen, the Adeli Suit, patterning, electrical stimulation, conductive education, equine-assisted therapy, craniosacral therapy, Feldenkrais therapy, and acupuncture. Unfortunately, these modalities have different degrees of published evidence to support or refute their effectiveness. Uncontrolled and controlled trials of hippotherapy have shown beneficial effects on body structures and functioning. Studies of acupuncture are promising, but more studies are required before specific recommendations can be made. Most studies of patterning have been negative and its use cannot be recommended. However, for the other interventions, such as hyperbaric oxygen, more evidence is required before recommendations can be made. The individual with CP and his or her family have a right to full disclosure of all possible treatment options and whatever knowledge currently is available regarding these therapies.     

Evaluation of a Combined Cognitive Behavioural Therapy and Interpersonal Process Group in the Psychotherapy Training of Clinical Psychologists

It is now widely acknowledged that both content and process elements of psychotherapy play a part in client treatment outcomes. Despite this, there are pressures on Australian clinical psychology training programs to teach evidence‐based approaches in a relatively short time frame. Producing clinical psychology graduates who have an adequate level of competence in evidence‐based practice and meeting the demands of professional accreditation requirements can mean that less time is available to teach the process elements of psychotherapy. The aim of this study was to conduct a preliminary evaluation of a clinical psychology psychotherapy training program that combines an interpersonal process group with a cognitive behavioural therapy training model that incorporates self‐reflection and self‐practice. Eleven participants who participated in the training in 2008 completed the Counseling Self‐Estimate Inventory at pre‐ and post‐training. Significant improvements on the majority of the subscales of this inventory were found. A separate sample of nine trainees and clinical psychology registrars who also previously completed the program attended individual interviews in 2010 aimed at gaining their perspective regarding various aspects of the program. Self‐practice of cognitive behavioural therapy techniques was found to be important in the identification and management of trainees’ own core beliefs, and to their appreciation of how challenging this process may be for clients. The interpersonal process group was described by participants as enhancing their competency as psychotherapists. Common themes included the experience of anxiety and a high level of emotion, and understanding how this experience might be similar for clients; increased self‐awareness; and increased competence in process issues. Many participants believed the process and content components of training were equally important to their development as psychotherapists.     

Computer-Assisted Therapies: Examination of Therapist-Level Barriers to Their Use

Despite enthusiasm in the field for their potential ease of dissemination, little work has examined whether practicing clinicians are willing and able to use computer-assisted therapies (i.e., computerized treatments designed to be administered with therapist support). For therapists to use these tools, they require access to computer equipment, the skills needed to use the equipment, and willingness to adopt the technology in treatment. This study examined these three factors using survey data from a national sample of mental health clinicians (N = 1,067). Respondents reported on their access to technology and computer fluency, in addition to completing the Computer-Assisted Therapy Attitudes Scale (CATAS), a measure of therapist attitudes designed for this study. Overall, the majority of therapists (90.7%) reported access to at least one computer at work and self-reported computer fluency levels were high. On average, therapists held positive attitudes towards computer-assisted therapies, although expressed concern that these technologies might damage rapport and did not feel that these technologies would improve treatment outcomes. Predictors of positive attitudes included greater general openness toward new treatments, greater comfort with computers, and easier access to technology at work (all ps < .01). Results suggested that, on the whole, therapists may be likely to integrate computer-assisted therapies into their clinical practice. However, therapists vary both in their ability and willingness to use these tools. Implications for the dissemination of computer-assisted therapies are discussed.     

Empirically Supported Complexity

Abstract— Over the last 10 years, evidence-based practice in psychology has become synonymous with a particular operationalization of it aimed at developing a list of empirically supported therapies. Although much has been learned since the emergence of the empirically supported therapies movement, its restrictive definition of evidence (excluding, for example, basic science as a source of evidence to be used by clinicians) is problematic, and the assumptions inherent in its nearly exclusive focus on brief, focal treatments for specific disorders are themselves not generally supported by the available data. Recent meta-analytic data support a more nuanced view of treatment efficacy than one that makes dichotomous judgments of empirically supported or unsupported, suggesting the need for a more refined concept of evidence-based practice in psychology.     

Introduction: novel therapies in developmental disabilities--hope, reason, and evidence

Complementary and alternative medicine (CAM) is used both alongside (complementary) and as a substitute for (alternative) conventional therapies. Although CAM use is reported to be high among children with typical development, reported rates for CAM use to address symptoms of children with developmental disabilities may be higher. Increased use in this population may relate to hope for amelioration of symptoms, concerns regarding side effects of conventional treatments, and a need on the part of families to participate in decision making regarding their child's care. Primary health care providers may find that the child's needs are best served when they maintain a dialogue with families to evaluate the evidence supporting novel therapies. Interventions need to be assessed in an evidence based fashion whether or not they are initially preceived as CAM. This issue of Mental Retardation and Developmental Disabilities Research Reviews contains reviews of CAM used to treat several developmental disabilities as well as some broader discussions related to the determinants of CAM use, current efforts to evaluate novel therapies, and how to consider the possibility of placebo effects.     

Mindfulness-Based Approaches with Children and Adolescents: A Preliminary Review of Current Research in an Emergent Field

Interest in applications of mindfulness-based approaches with adults has grown rapidly in recent times, and there is an expanding research base that suggests these are efficacious approaches to promoting psychological health and well-being. Interest has spread to applications of mindfulness-based approaches with children and adolescents, yet the research is still in its infancy. I aim to provide a preliminary review of the current research base of mindfulness-based approaches with children and adolescents, focusing on MBSR/MBCT models, which place the regular practice of mindfulness meditation at the core of the intervention. Overall, the current research base provides support for the feasibility of mindfulness-based interventions with children and adolescents, however there is no generalized empirical evidence of the efficacy of these interventions. For the field to advance, I suggest that research needs to shift away from feasibility studies towards large, well-designed studies with robust methodologies, and adopt standardized formats for interventions, allowing for replication and comparison studies, to develop a firm research evidence base.     

Novel treatments for autistic spectrum disorders

In no area of developmental pediatric practice is there more controversy regarding the choice of treatment than related to children with autistic spectrum disorders (ASD). Complementary and alternative medical therapies (CAM) are often elected because they are perceived as treating the cause of symptoms rather than the symptoms themselves. CAM used for autism can be divided by proposed mechanism: immune modulation, gastrointestinal, supplements that affect neurotransmitter function, and nonbiologic intervention. Secretin as a therapy for autism is discussed as an example of how a clinical observation rapidly grew to a widespread treatment before well-designed studies demonstrated absence of effect. The plausibility for behavioral effect was not substantiated by clinical studies. CAM used for treatment of autism is examined in terms of rationale, evidence of efficacy, side effects, and additional commentary. Families and clinicians need access to well-designed clinical evidence to assist them in choice of therapies.     

Antidepressant Medication: Is It a Viable and Valuable Adjunct to Cognitive-Behavioral Therapy for School Refusal?

Cognitive-behavioral therapy (CBT) is an evidence-based treatment for school refusal. However, some youth do not respond to CBT. The serious risks associated with school nonattendance call for novel approaches to help those who do not respond to CBT. Because school refusal is commonly associated with anxiety disorders, and the combination of CBT and antidepressant medication enhances outcomes in the treatment of anxiety disorders, combined treatment may be effective for school refusal. This narrative review evaluates the current evidence base for adding antidepressant treatment to CBT for school refusal. Six randomized controlled trials (RCTs), two open trials, six case studies/series, and one observational study were identified and reviewed. There is support for combined CBT and imipramine, but this medication is not typically used due to the risk of concerning side effects. Two recent RCTs failed to provide evidence for the superiority of combined CBT and fluoxetine. Further research in this area is required because the extant studies have a number of methodological limitations. Recommendations are provided for clinicians who consider prescribing antidepressant medication or referring for adjunctive antidepressant treatment for school refusal.     

Chapter 1 Pluralism,Pragmatism, and the Therapeutic Endeavor in Brief Dynamic Treatment

Abstract

This article places representative formulations of brief dynamic psychotherapy in the larger context of psychoanalytic thought, reviews relational perspectives that inform contemporary approaches to time-limited treatment, and identifies tasks in continued development of theory, research, and practice. In doing so, it emphasizes the need to consider a broader range of psychopathology, dysfunction, and need in formulations of brief intervention and to develop more flexible and realistic approaches in treatment of vulnerable and underserved populations. The growing emphasis on theoretical pluralism and pragmatism in therapeutic practice generally should facilitate efforts to broaden the base of brief dynamic treatment.     

Evaluating Single-Subject Treatment Research: Lessons Learned from the Aphasia Literature

The mandate for evidence-based practice has prompted careful consideration of the weight of the scientific evidence regarding the therapeutic value of various clinical treatments. In the field of aphasia, a large number of single-subject research studies have been conducted, providing clinical outcome data that are potentially useful for clinicians and researchers; however, it has been difficult to discern the relative potency of these treatments in a standardized manner. In this paper we describe an approach to quantify treatment outcomes for single-subject research studies using effect sizes. These values provide a means to compare treatment outcomes within and between individuals, as well as to compare the relative strength of various treatments. Effect sizes also can be aggregated in order to conduct meta-analyses of specific treatment approaches. Consideration is given to optimizing research designs and providing adequate data so that the value of treatment research is maximized.     

Treatment of Anxiety Disorders With Comorbid Depression: A Survey of Expert CBT Clinicians

Cognitive-behavioral therapy (CBT) is an empirically supported psychological treatment for anxiety disorders. These treatments have primarily been developed to target primary anxiety disorders, despite the fact that these disorders frequently co-occur with a diagnosis of depression. Empirical evidence provides guidance regarding how to treat an individual with a primary anxiety disorder with comorbid depression; however, there is limited data regarding how to translate these findings into clinical practice. Improving our understanding of how CBT is currently being used in practice among experts is integral to learning whether modifications to protocols lead to more or less effective treatments. Accordingly, we surveyed expert CBT clinicians about their assessment and treatment approaches and what challenges they face in formulating and treating mood and anxiety comorbidity. Most experts reported that their assessment includes a semistructured interview and self-report measures to determine breadth and hierarchical ordering of comorbidity severity. Symptom severity, client's goals, temporal onset of disorders, presence of suicide risk, and potential for early treatment success were reported as factors to consider when deciding where to begin treatment. Almost three quarters of experts surveyed indicated that they usually take some type of sequential treatment approach when treating primary anxiety disorders with comorbid depression. The top three reported challenges associated with treating comorbid presentations were client's motivation/energy, hopelessness/pessimism, and ongoing need for risk assessment. Implications for the nature and timing of CBT interventions in “real-world” clinical practice are discussed.     

An Integrative Approach to Somatoform Disorders Combining Interpersonal and Cognitive-behavioral Theory and Techniques

Data regarding the treatment of somatoform disorders suggest that the gains associated with current psychopharmacologic or psychotherapeutic treatments are modest at best. There have been a few moderately effective treatments for selected functional somatic syndromes, but patients who present with multi-system symptoms meeting criteria for the DSM-IV somatoform disorders are notoriously unresponsive to treatment. Experts in the field have advocated several approaches, including interpersonally oriented and cognitive-behavioral therapies, and have emphasized the importance of the provision of reassurance within the doctor-patient relationship. While each individual approach has merit, none is likely to be maximally efficacious as a stand-alone treatment. In this article we describe the theoretical underpinnings and technical aspects of a treatment for somatizing patients that integrates these three elements.     

A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions

Although CBT for psychosis (CBTp) has been recommended as a best practice since 2002, CBTp’s availability is quite limited in the U.S. Integration of CBTp-informed interventions into the milieu of the treatment settings in which the majority of the 2.4 million Americans with psychosis receive treatment may greatly improve access to those services. This paper presents an evidence-based model for training line staff in CBTp principles, in order that more staff throughout the U.S. might better support the recovery of people with psychosis in this way. Examples are provided to illustrate effective strategies and approaches.